Talk of healthcare reform is everywhere. You can’t turn on a TV, read a newspaper or surf the Internet without reading someone’s “expert” opinion on the topic. But there is reform actually going on in healthcare that most people don’t know about, unless you are one of the employees or patients in the Veterans Affairs healthcare system.
Quietly during the past few years, the system’s nutrition and food service department—officially known as the Office of Nutrition and Food Services/Medical Surgical Services within the Office of Patient Care Services—has been renovating its program and remaking the image of the 153 medical centers and 132 community living centers in the VA system.
The foodservice changes the VA healthcare system is making touch just about every operational facet. The department is giving its patients more food options, changing patient meal delivery, improving food safety, going green and making culture changes in its community living centers, formerly known as nursing homes.
Ellen Bosley, national director of nutrition and food services, says the overhaul is designed to address a new population of veterans, improve patient satisfaction and to keep current with dining trends. “Our newer customers are returning veterans from the Iraqi and Afghanistan wars,” she says. “When I started in the VA in 1978, we had non-selective menus. Today we have more selective menus and we are going more to that approach to meet the changing needs of our customers.” The VA’s patient base isn’t only getting younger, there are more women as well.
In a system as large as the VA and with so many employees—nearly 8,000 in food and nutrition—it is daunting to implement such extensive changes. Last year, apporximately 5.6 million veterans were seen in a VA facility. If there is one thing the VA’s nutrition and food services department does well it is collaboration. “You can identify people who are doing out-of-the-box things,” says Margaret Rogan, clinical nutrition manager at 300-bed Northport VA Medical Center in New York. “We share everything. If someone has a good room service menu, they will send it to you in its entirety. There are no territories.”
Community living centers: That collaboration is one of the reasons the system has been able to make so many changes in a relatively short time. One of the biggest changes started several years ago in the community living centers (CLC), which were formerly called nursing homes. “Community living centers are generally located on the same campus as the acute-care hospitals, and as a result the VA has used the medical model for healthcare delivery for the community living centers,” says Barbara Harrington, chief of nutrition and food services at 414-bed Bay Pines in Florida. “We treated the patients in the CLCs who might be there for six months just like we treated patients in the hospital who were there for four or five days.”
However, with the changing patient population, Harrington says the CLCs are moving to a more individualized approach. Two years ago, a culture change began in the CLCs, which is designed to create a home-like atmosphere. Some changes are small—baking cookies on the units or hosting a happy hour, for instance, but some of the changes are more complex, such as selective breakfasts and room service.
For example, at Bay Pines, Harrington has started a hot breakfast cart that is taken to the dining rooms. The residents choose items from a spread of breakfast options, which they eat in the dining room with other residents. Before this change, the patients were served a non-select breakfast tray in their rooms.
At the James A. Haley VA Hospital in Tampa, Fla., a Friday happy hour from 2 to 4 p.m. gives the residents and staff a chance to socialize over non-alcoholic beers. “Part of this culture change and transformation is to have a closer bond and a more family-type atmosphere,” Harrington says.
Birthday parties, resident-tended gardens, visiting chefs and cooking groups are other activities designed to help create this family atmosphere.
Food delivery changes: Some of these same types of changes can be found in the hospitals. “There was a point when non-selective menus were the direction we were given,” says Linda Allen, clinical nutrition manager at the 500-bed Milwaukee VA Medical Center.
During the past 10 years, that has changed, with more facilities moving toward selective menus and implementing meal delivery systems besides the traditional trayline. In addition, several of the VA facilities have implemented room service or pod assembly systems. Several facilities use a spoken menu, including the Roudebush VA Medical Center in Indianapolis, where Mary Pat Lynch is the chief of nutrition and food services. Recently the trayline was removed. Now employees take carts to the units with several options for each meal. The residents can then select which meal option they would like.
“We all identify that our population is changing,” Lynch says. “The expectations of a young veteran and the expectations of an older veteran are vastly different with regard to food. When we have the [older] vets, generally the attitude is, ‘we were all in the army together so just slap something on my tray and I’ll eat it.’ When you ask what they eat, they say, ‘I eat what my wife puts in front of me.’ A great majority are used to eating at home and that meal contains meat, potatoes, vegetables and bread. When we get the young guy who comes in, he says, ‘what is this? I don’t eat like this.’ Now we are asking, what is it that is going to make them happy. One thing that makes all of us who are younger happy is choice.”
Healthy diet initiative: Giving patients more choices doesn’t mean filling up a menu with french fries, pizza and doughnuts. The VA system is working to implement a healthy diet initiative, which has certain criteria that facilities will have to follow for their regular diets. The criteria includes daily caloric intake between 2,000 and 2,400 calories; between 25% and 35% of calories from fat—and between 10% and 15% of that is recommended from mono-unsaturated fats— eliminating trans fats; cholesterol between 200 and 400 milligrams a day; sodium between 2,000 and 4,000 milligrams a day; between 25 and 35 grams of fiber a day; offering fruits and vegetables at least five times a day; daily protein intake between 60 and 120 grams a day; offering at least two cups of skim or low-fat milk a day; and incorporating more fruit-based desserts. The initiative is not yet a mandate, according to Chris Johnson, chief of nutrition and food services at the Hines (Ill.) VA Hospital.
The healthy push started with a survey 15 months ago, Johnson says. The survey reported some promising results, such as the fact that two-thirds of VA facilities were offering five servings of fruits and vegetables a day and more than two-thirds were serving higher-fiber cereals and breads.
“Most people had plans to do something with healthy food, so this initiative allowed them to have ‘oomph’ behind their plans,” Johnson says.
Johnson says the healthy initiative is a response to increasing health risks that poor diets contribute to. About 76% of veterans are considered overweight or obese, 24% have diabetes and 36% are hypertensive.
MOVE!: Those statistics are one reason behind another VA program called MOVE!, which is a weight management program that was mandated in 2006. Every patient who comes into a VA medical facility is screened for height, weight and age. If a patient is overweight or obese, he can enroll in MOVE!. Each patient’s program is tailored to the results of the MOVE!23 questionnaire, which asks questions about a patient’s medical history, how a patient eats and how active a patient is.
“MOVE! is a self-management program,” says Lynn Novorska, MOVE! dietitian coordinator. “One element consists primarily of telephone support and another is group care. We work with patients to establish goals for weight loss and physical activity, modify what and how they eat, as well as their weight-related behaviors.” While a healthy diet is a primary focus for MOVE! participants, other areas that affect weight management, such as physical activity and psychological factors, are also addressed.
Although MOVE! is a national program, each VA facility has a MOVE! coordinator, many of whom are dietitians. There are 189,000 veterans enrolled in MOVE! and about 12% of the patients offered enrollment in MOVE! enter the program.
Research and benchmarking: One benefit of being a part of the nation’s largest integrated healthcare system is the wealth of available information. One area of information is from the research done by the system’s registered dietitians. “VA dietitians are actively engaged in research opportunities, which incorporate nutrition factors in an attempt to demonstrate positive outcomes of nutrition education and intervention,” says Patricia Bryant, chief of nutrition and food services at the 624-bed Central Arkansas VA healthcare system in Little Rock.
One VA study focused on the results of the MOVE! program at the Minneapolis VA Medical Center. The study found that 63% of MOVE! participants who completed the 10-week program lost at least 2% of their body weight. Thirty-five percent lost at least 5% of their body weight.
Another study, the Veterans’ Walk for Health, was conducted at five large medical centers four years ago. Veterans were given pedometers and told to walk a certain number of steps each day. The study found that “incorporating Internet-mediated pedometers with automatic uploading, online tracking and tailored feedback into a traditional nutritional weight-loss program [resulted] in greater weight loss in sedentary high-risk veterans than walking programs that use time-based walking goals for simple pedometers that require manual logging.”
Bryant says a study about calcium and bone loss in female veterans could be a possibility as the female veteran population increases.
In addition to research studies, the VA system collects information through annual reports and event capture, a program that records the workload of dietitians. “Event capture records inpatient and outpatient workload, and it gives information about who provided the service, the patient and what service was provided,” says Allen at the Milwaukee VA Medical Center. “It’s all put into an electronic program, sent to a central location where it captures all of the information and processes it, and then allows you to look at the data in different ways. We are planning to use that data in a staffing model for dietitians.” Event capture started in 2006.
Green team: Like many other operations, the VA system is implementing green and sustainable practices. The green committee, which includes Christine Immel, administrative registered dietetic technician at the Milwaukee VA Medical Center, and Barbara Hartman, chief of nutrition and food services at the 566-bed Martinsburg (W.V.) VA Medical Center, developed a checklist to help the directors get on the “green” path.
The checklist is broken up into five sections: energy conservation, water conservation, waste management, food and beverage procurement, and implementation of policies, planning promotions and process improvement. Under each section, there is a list of items that can be implemented to make a facility more “green.” For example, under energy conservation, there is the use of lids on food wells and range pans and using programmable ovens. For each item on the checklist, three points are awarded if a facility is currently doing that item, two points are awarded if a facility plans to implement the item in less than one year and one point is awarded if the item is a long-term goal. An operator can use the points total to get a baseline count, which can be used to benchmark the facility’s progress.
The checklist was released to the system in April and includes resources for additional information.
“I had a few people that said this has demystified the whole sustainability topic for them because it helped them see what it really involved,” Hartman says. “Some people hadn’t really put all the pieces together. Some hadn’t realized that they had a low-flow water valve on their sinks and that that is a good thing.”
Food safety and defense: A year and a half ago the VA system commissioned a food safety and defense study to see where the system could enhance food safety and defense, according to David Phillips, chief of nutrition and food services at the 484-bed Salisbury (N.C.) VA Medical Center. The results of that study included recommendations to enhance the HAACP program, improving the food recall process and making sure that areas are secure. All VA facilities are on a national prime vendor contract, through which the facilities purchase apporximately 90% of their food. Phillips wants to enhance the recall system for the 10% of items that are not purchased on the prime vendor contract, something he says they are currently working on.
“Intelligence reports indicate that federal agencies are potential threats from bioterrorists and we are doing everything possible to be sure our food supply remains safe,” Bosley from the national office says.
To ensure this safety, Phillips created a food safety checklist for operations, much like the environment list. The list is broken down into four categories: receiving, production, storage and personnel. Some of the items on the checklist include making sure there are cameras in isolated areas and that the doors are secure in the receiving area so that only people with access can enter.
“This is a proactive checklist to make sure everything is in place to prevent [these types of threats],” Phillips says.